IFrailty in liver transplantation: implications for perioperative management and postoperative outcomes

Frailty, a multidimensional syndrome characterized by diminished physiological reserve, is a key determinant of outcomes in liver transplantation (LT). Among patients with end-stage liver disease, frailty manifests through physical, cognitive, and psychosocial impairments that complicate perioperative management and hinder recovery. This review explores the pathophysiological underpinnings of frailty, its clinical relevance for transplant teams, and emerging strategies for its assessment and reversal.

Frailty affects up to one-third of LT candidates and is independently linked to higher rates of postoperative complications, infections, prolonged ICU stays, and mortality. Objective frailty assessment tools enhance risk stratification and guide individualized interventions. Prehabilitation programs - encompassing exercise, nutritional optimization, and novel therapies such as senolytics and mRNA-based approaches - have shown promise in improving functional status and reducing perioperative risk. At the University of Pittsburgh, structured frailty protocols are fully integrated into LT evaluation and care.

Frailty is a modifiable risk factor with profound implications for LT outcomes. Routine frailty screening, coupled with targeted multidisciplinary interventions, can optimize candidate selection, reduce complications, and improve long-term recovery. Ongoing research is needed to identify and standardize the most effective strategies for reversing frailty in this high-risk population.